Mental health articles

substance misuse case study: Ray

To illustrate some of the treatment interventions, which can be used with people with a dual diagnosis, Ray’s case is considered further. Ray was referred to the substance misuse team from an inpatient psychiatric ward where he had been admitted following a deterioration in his mental state. This had stabilized and it was suggested that he might benefit from input for his substance misuse. The nurse visited him on the ward to begin the engagement process and gain some assessment information. Ray appeared open to looking at his use.

Confidentiality was discussed and Ray was happy for information to be shared between the substance misuse and mental health teams, and his GP. He talked openly about his use. He had recently been in trouble with the police and been in a fight in which he was badly assaulted. He said he had had enough of this sort of thing and wanted to cut down his drinking. From the outset the nurse sought to elicit such change talk to build his motivation. In order to maximize the chances of engaging Ray, initial sessions were held on the ward. Information to supplement that obtained by the substance misuse nurse was sought from Ray’s CMHN and GP. An important early intervention was giving Ray information about units of alcohol and the possible effects that substance misuse could have on his physical and mental health as his knowledge base was low. Results of blood tests were obtained and showed abnormalities consistent with heavy drinking. These were explained to Ray and appeared to further motivate him. In the week following his hospital discharge Ray managed to remain abstinent from alcohol for four days. On each of those days he cooked himself a meal and began an exercise regimen. He was given positive feedback regarding this. Some discussion followed about what had been different on these days to those when he drank. Ray was unsure and it was suggested that he complete drink diaries which might provide some insights. Completing the diaries made Ray realize how much he was drinking and the amount of money he was spending on alcohol – he was surprised at this. They also enabled him to identify risk situations. These included: having money, one particular friend who often suggested they go to the pub, and boredom. During one session Ray and the nurse together worked on completing a decision matrix. Among the potential advantages of stopping use were: the possibility of resuming a relationship with a past girlfriend (this ended because of his substance use), no longer ending up with cuts and bruises from falling or getting into fights when drunk, staying out of trouble with the police, getting some training to equip him for work, and having money to pay off his debts and eventually spend on things he wants, such as new clothes. As time progressed, Ray started to attend appointments at the substance misuse team. He continued to complete drink diaries and these were discussed in sessions. Ray’s drinking and drug use fluctuated. Some weeks he managed to remain completely abstinent and on others he would drink most days and use drugs if they were available. During the period after his mother’s death he drank heavily for over two months. Ray came to recognize that when he was using more drugs he tended to be more paranoid. He also reported that when he was not drinking he felt much better, physically and emotionally. Ray had often talked about attending a local alcohol agency which had a drop-in facility but he seemed unable to get there so the nurse went with im. After spasmodic attendance for a period he began attending regularly. Sometimes he would attend groups there too. This helped Ray to structure his time and his drinking reduced further. He increased contact with his brother and sister and enjoyed spending time with his nephews. The alcohol project ran a six-week structured day programme which required people to be abstinent during the course. Sessions were included on alcohol and health, assertiveness, dealing with emotions, problem solving and relapse prevention. Ray thought this would be helpful. It took him several months before he had minimized his drinking to a level where he realistically thought he could be abstinent for six weeks. However, he achieved this and is now attending the programme. He has also started looking for vocational courses which he might begin afterwards and has commenced acamprosate, a drug which helps to deal with craving. Ray is doing very well and there have been marked changes in his substance use and lifestyle over the past two years

. However, (re)lapse is always a possibility. If/when he does lapse, it will be important to see this as a learning experience which can be overcome. In the meantime the professionals involved in his care continue to liaise and seek to provide a coordinated approach to his care.

 

Tags: case study, substance misuse